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The effects of self-management and positive reinforcement on The effects of self-management and positive reinforcement on

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Cari McGaffney Bonner Rowan University

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THE EFFECTS OF SELF-MANAGEMENT AND POSITIVE REINFORCEMENT ON

THE OFF-TASK BEHAVIOR OF STUDENTS WITH ADHD

byCari McGaffney Bonner

A Thesis

Submitted in partial fulfillment of the requirements of the Master of Arts Degreeof

The Graduate Schoolat

Rowan UniversityMay 8, 2003

Approved byProfestr '-

4 I/D5Date ApprovedI I

"

. .

ABSTRACT

Cari McGaffney BonnerTHE EFFECTS OF SELF-MANAGEMENT AND POSITIVE REINFORCEMENT ON

THE OFF-TASK BEHAVIOR OF STUDENTS WITH ADHD2002/03

Dr. Joy XinMaster of Arts in Special Education

The purpose of this research was to evaluate the effects of self-management

strategies together with positive reinforcement to reduce the off-task behavior of children

with ADHD. Three first and second grade students with ADHD and classified with a

disability attending an elementary school participated in the study. Students were taught

to self-monitor their behaviors in their special education classroom. They were trained to

record their behaviors by completing a self-management form that consisted of 7 items at

the end of each school day. Three off-task behaviors: out-of-seat, calling out and

interrupting instruction were observed. The decrease of the student target behaviors was

positively reinforced. An A-B-A-B withdrawal design was used in the study. Behavior

occurrences were recorded using a checklist during baseline and intervention phases.

The repeated application and withdrawal of the intervention made it possible to determine

the change of the behaviors being measured. The results indicate a positive decrease of

all children's behaviors of out-of-seat and interrupting instruction, however, the calling

out behavior was not reduced. The findings provide support to previous research to

suggest a cognitive-behavioral approach to meet the needs of students with ADHD and

i

add data and implication for fiture research to further enhance the effectiveness

of self-management for students with ADHD.

ii

MINI-ABSTRACT

Cari McGaffney BonnerTHE EFFECTS OF SELF-MANAGEMENT AND POSITIVE REINFORCEMENT ON

THE OFF-TASK BEHAVIOR OF STUDENTS WITH ADHD2002/03

Dr. Joy XinMaster of Arts in Special Education

The purpose of this study was to evaluate the effects of self-management

strategies together with positive reinforcement to reduce the off-task behavior of students

with ADHD. Three first and second grade students with ADHD and classified with a

disability participated in the study. Students were taught to self-monitor their behaviors.

They were trained to complete a self-management form that consisted of 7 items at the

end of each school day. Their decrease of the target behavior was positively reinforced.

An A-B-A-B withdrawal design was used in the study. Student behavior was observed

and recorded during baseline and intervention phases. The results indicate a positive

decrease in out-of-seat and interrupting instruction behavior. The findings provide

support to previous research to suggest a cognitive-behavioral approach to meet the needs

of students with ADHD.

iii

ACKNOWLEDGEMENTS

I would like to thank all of the people who contributed in some way to this

thesis. My husband Bob, for having faith in me through this process. My parents, for

always encouraging and supporting me. Sharon Spriggs, my computer expert, for putting

this whole project into one document. Dr. Xin, for her guidance and supervision of this

complete project.

iv

TABLE OF CONTENTS

Chapter 1: Introduction ........................................................................... 1-7

Statement of Problems ............................................................................ 1

B ackground ......................................................................................... 5

Significance of the Study ......................................................................... 6

Statement of the Purpose .......................................................................... 7

Research Questions ................................................................................ 7

Chapter 2: Review of Literature ................................................................ 8-24

Behavioral Characteristics ........................................................................ 11

Interventions ......................................................................................... 14

Sum m ary ............................................................................................. 24

Chapter 3: Method .............................................................................. 25-29

Subjects .............................................................................................. 25

Setting ............................................................................................... 25

Research Design .................................................................................... 26

Training M aterials .................................................................................. 26

Training Procedures ................................................................................ 26

Observation Procedures ............................................................................ 27

Interobserver Reliability ........................................................................... 27

Figure 1: Self-Recording Form .................................................................. 28

Figure 2: Training Procedures .................................................................... 29

v

Chapter 4: Results .............................................................................. 30- 32

Figure 4.1: Out of Seat ............................................................................. 30

Figure 4.2 ........................................................................................... 31

F igure 4.3 ........................................................................................... 31

Chapter 5: Discussions ........................................................................ 33-36

R eferences ....................................................................................... 37-40

A ppendices ........................................................................................... 41

vi

Chapter 1

INTRODUCTION

Statement of Problems

One of the most prevalent childhood disorders reported by schools is Attention

Deficit Hyperactivity Disorder (ADHD) (D'Alonzo, 1996). Children with ADHD are

being diagnosed after parents describe their child's problem behaviors to their

pediatrician (Fewell & Deutscher, 2002). Common characteristics of this population

include inattention, impulsivity, and hyperactivity (American Psychiatric Association,

1994). These children are identified by their constant, spontaneous, uncontrollable, overt,

and purposeless behavior (Calhoun, Greenwell-Iorillo, & Chung, 1997). Many children

with ADHD physically move a lot, without paying attention, and are often

nonconforming, and disruptive in class, therefore, they do not function well in school.

Their characteristics and behaviors interfere with their learning. These children are often

underachieving and accused of lack of motivation by frustrated teachers. Such adverse

experiences can seriously affect their self-esteem and feeling of competence (Henker &

Whalen, 1989). Some of them continue to exhibit behavioral problems, poor academic

performance, cognitive impairment, low self-esteem, and difficulty with peer

relationships even in their adulthood (Woods, 1986).

The common inappropriate behaviors of children with ADHD are calling out

answers, leaving seat without permission, and interrupting instruction (Montague &

Warger, 1997). Some of them lack impulse control and blurt out answers prior to the

question being completed in class (Montague & Warger, 1997). Additionally,

1

hyperactivity and overactivity may result in making noises at inappropriate times

during classroom instruction. However, these behaviors appear out of the child's control

and tendencies vary in frequency among children with ADHD. The more frequent the

inappropriate behavior, the greater the need for intervention. Teachers spend a large

amount of instructional time trying to manage these behaviors that may affect the

instructional time of the entire class. A behavior management system seems imperative

to reduce these inappropriate behaviors.

Medication is the most common intervention for children with ADHD. Stimulant

drugs, such as Ritalin and Adderall will mimic brain neurotransmitters and produce and

arouse the central nervous system (Ballard et al., 1997). There are several prescribed

stimulant medications that have made positive impacts. These stimulants quickly pass

through the blood stream to the brain to improve attention (Pelham, Harper, McBurnett,

Milich, Murphy, Clinton, & Thiele, 1990). However, this improvement was noted in

limited areas through numerous studies, such as performance and skill areas including

intelligence, but academic testing was not impacted (Ballard et al., 1997). In addition,

drug therapy may involve risks. Many variables must be taken into account before drug

therapy is recommended for a child. For example, short-term side effects include

headaches, nausea, weight loss and fatigue, and long-term effects are uncertain (Barkley,

1990). It is not sure if the drug would cause cardiovascular problems in the future.

Additionally, a weakened sensitivity to reward cues and enhanced reactivity to

punishment cues are found among children taking Ritalin (Arnett et al, 1996). Because

schools cannot determine the use of medication, using pharmacological approaches to

intervention remains inconsistent and controversial (Montague & Warger, 1997).

2

Behavioral intervention has proven advantageous over the other methods to

manage the behaviors of children with ADHD. These interventions include positive and

negative reinforcement, punishment, and a combination of both procedures. The earlier

the behavior is identified and an intervention is implemented, the more likely the

behavior can be modified before it becomes a more serious barrier to learning (Fewell &

Deutscher, 2002). Behavioral intervention can be used with children who do not respond

well to medication or for whom the use of medication is contraindicated by other

problems (Pelham, 1991). Implementation of the behavioral intervention must be

lengthy, consistent and intensive (Pelham, 1991). For effectiveness, these interventions

should be used at school in conjunction with the family to support the intervention at

home. It is found that "behavioral treatments may help families actively cope with their

child's disorder and make necessary life accommodations to optimize family

functioning" (MTA Group, 1999). However, limitations arise when using the

behavioral intervention approach. There are many variables that must be considered

prior to implementing a behavioral treatment strategy. These variables including teacher-

training, severity of student's disability and time, may impact the effect of intervention

treatment. Treatments must be of sufficient intensity and duration to have an immediate

impact of the core ADHD symptoms. Additionally, the behavioral intervention alone

rarely supplies enough support to maintain adequate functioning (Schachar et al., 2002).

Cognitive intervention is suggested in hopes that changes in thinking will result in

changes in behavior. The use of cognitive intervention in treating ADHD was a result of

the success this type of intervention had in treating depression and anxiety (Frazier &

Merrell, 1997). Early research in the 1980's produced disappointing results. However,

3

there is resurgence in research using cognitive techniques. Contemporary cognitive

interventions have a behavioral connection (Frazier & Merrell, 1997). These cognitive-

behavioral approaches have proven successful. Self-monitoring is one of the cognitive

intervention strategies. It refers to behavior change programs that promote self-

monitoring of behavior and/or performance and ultimately delivery of self-reinforcement.

This strategy can be used to document whether or not a target behavior was displayed

during a period of time (Quinn, Swaggert, & Myles, 1994). Teachers may play a role of

facilitator to model the strategy and to evaluate the individual's behavior change. This

type of intervention relies heavily on self-evaluation. Self-evaluation is difficult to be

used exclusively when working with young students who have additional cognitive

disabilities.

The present research will investigate the use of a combination of cognitive and

behavioral intervention methods. Cognitive behavior modification techniques teach self-

control through increased awareness of cognitive processes and knowledge of how

behavior affects academic and behavioral outcomes. This combination will emphasize

students rather than teacher's evaluation of their performance (Swaggert, 1998). It will

be implemented to increase attentive behavior of children with ADHD. Three-targeted

behaviors will be addressed through a positive reinforcement program. The positive

behavioral reinforcement will be combined with a cognitive approach of intervention

using self-management and a self-recording checklist. Students will be taught through

the teacher's modeling, and practicing with appropriate responses. The outcomes of the

student performance will be examined.

4

Background

A physician investigated ADHD in 1923. He became fascinated with the disease

"epidemic encephalitis" and found that children with the disease were: talkative, irritable,

hyperkinetic, and impulsive (Calhoun, et al., 1997). Over the past eighty years, the name

continuously changed while the symptoms remained. In the last decade, ADHD has

received significant attention in education and counseling communities, with some

considering as a life long disability (Silver, 1992). It is found that nearly 2 million

children have ADHD symptoms (Dulcan & Popper, 1991). This prevalence challenges

educators to consider the impact on a child's development, classroom management, and

learning success (D'Alonzo, 1996).

In 1960 Freibergs and Douglas compared normal and ADHD children in their

study and reported that ADHD children responded better on specific tasks where the

teacher utilized partial reinforcement techniques. This was the first study to demonstrate

the advantages of positive behavioral interventions for children with ADHD. In their

study, behavioral interventions were utilized to change unwanted behaviors through the

manipulation of environmental antecedents and consequences. It is called behavior

modification. The use of behavior modification frequently results in improvement of

behaviors, but can be extremely difficult for the child's family to apply (Breakstone,

1987). In 1980, research on cognitive interventions was suggested and advocated.

Cognitive techniques such as self-monitoring with a wide variety of treatment procedures

tend to be a cognitive-behavioral nature (Frazier & Merrell, 1997). These interventions

aid in generalization and maintenance of appropriate behaviors by promoting self-

monitoring. A wide variety of treatment procedures fall under the cognitive-behavioral

5

intervention strategy such as, self-control, self-reinforcement and self-evaluation. These

multimodal treatment approaches are supplemental and extend the treatment gains of

single modal approaches (Frazier &Merrell, 1997).

The present research was designed partly following the research procedures used

by Hutchinson, Murdock, Williamson, and Cronin (2000) to study combine self-

management strategy, self-recording with points and teacher praise. It emphasized on

decreasing a student's time to begin an assignment and increasing the on-task and

nondisruptive behaviors through self-encouragement. However, instead of providing

intervention to a student in an advanced first grade in the previous research, this study

will be conducted in a special education classroom for students with multiple disabilities.

Instead of addressing the effects of this strategy in a reading class, this study will be

conducted throughout the day including reading, math and less structured instructional

times such as calendar activity and writing period.

Significance of the Study

Educators are confronted daily with students who are diagnosed with ADHD.

ADHD is often misinterpreted by educators and can be mistreated. This mistreatment

hampers the performance of children with ADHD throughout the educational setting.

Although multiple treatment approaches have been made available to educators,

inconsistencies of implementation still exist. The lack of knowledge and consistency of

interventions are critical factors that influence the effect of strategies to help children

with ADHD (Montague & Warger, 1997).

For students with ADHD, it is imperative to examine intervention methods, to

change their inappropriate behavior. Recently research has focused on different

6

strategies to reduce inappropriate behaviors of these students including multimodal

strategies (Frazier & Merrell, 1997). Self-management is a simple way to teach students

to monitor and control their own behavior (Alberto & Troutman, 1999). It has been

demonstrated that self-management combined with positive reinforcement was effective

in first grade reading class (Hutchinson et. al, 2000). However, little research has been

found to use this combined strategy for students with multiple disabilities in a special

education class. This present study will design a self-management strategy combining

with positive reinforcement to decrease off-task behavior of children with ADHD. The

effectiveness of multiple management techniques will be examined.

Statement of the Purpose

The purpose of this study are to evaluate the effects of self-management together

with positive reinforcement to manage the off-task behavior of children with ADHD.

Research Questions

1. Will the strategy of both self-management and positive reinforcement reduce the

out-of-seat behavior of students with ADHD?

2. Will the strategy of both self-management and positive reinforcement reduce the

calling out behavior of students with ADHD?

3. Will the strategy of both self-management and positive reinforcement reduce the

interrupting instruction of students with ADHD?

7

Chapter 2

REVIEW OF LITERATURE

Attention deficit hyperactivity disorder (ADHD) has been receiving considerable

attention among educators (Aust, 1994). Magazines, newspapers, network newscasts and

television talk shows focused on the condition in lay terms, whereas scientific and

educational journals described its biological and/or neurological bases. This attention

motivated physicians, parents, and teachers to search ways to help children affected by

ADHD learn better at home and in school (Aust, 1994). The conditions associated with

ADHD cause many learning, social and emotional problems. As a result, children with

ADHD experience great difficulty in learning, where attention and impulse control are

requirements for success (Fowler, 1994). This chapter will review relevant research on

ADHD symptoms, behavioral characteristics and different models of intervention.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

(DSM-IV, 4th ed.) states "the essential feature of Attention-Deficit/Hyperactivity

Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is

more frequently and severe than it is typically observed in individuals at a comparable

level of development" (American Psychiatric Association [APA], 1994, p.78). When

diagnosing ADHD, some symptoms must have been present before age 7 in at least two

settings. There must be interference with developmentally appropriate social, academic,

or occupational functioning that is not accounted for by another mental disorder.

Although most individuals display symptoms of both inattention and

hyperactivity/impulsivity, some show one predominant pattern. After evaluating six

8

months' of behavior, a diagnosis of ADHD is made and categorized in one of the

following areas: combined, predominantly hyperactive-impulsive, or not otherwise

specified. (APA, 1994).

All youngsters exhibit behaviors associated with ADHD to some degree in certain

situations. Thus, identifying a student of ADHD requires a multifaceted diagnosis and

evaluation process (Montague & Warger, 1997). Comprehensive assessment of children

with ADHD for educational purposes is a multistage, multimodal process that gathers

information to make decisions about the nature of children's educational problems. The

previous definition is used by educational psychologists to determine the presence of the

condition in children who are referred by their teachers and parents. An estimated 3% to

5% of school-aged children have ADHD (Montague & Warger, 1997). For some

children, the behaviors symptomatic of ADHD may seem to improve in adolescence.

ADHD, however is a lifelong condition manifested in different ways during a child's

developmental periods (Montague & Warger, 1997).

Barnett and Labellarte (2002) examined statistical figures to provide evidence of

the actual number of children diagnosed with ADHD, which is often difficult to estimate.

Evidence shows that the number of children with ADHD has increased in recent years,

these statistical figures may aid in answering the questions of whether ADHD is being

over-diagnosed (Barnett & Labellarte, 2002). The estimated prevalence of children with

ADHD in the United States is three to five percent (Barnett & Labellarte, 2002).

Approximately one to two children in a classroom have been diagnosed using structured

diagnostic interviews. The male and female ratio of children with ADHD is

9

approximately 4:1, though gender is not considered an independent risk factor (Cantwell,

1996). Estimated prevalence rates of ADHD differ in samples from different

countries, however, selected English-speaking countries each have a similar range

(Goldman, Genel, Bezman, & Slanetz, 1998). The diagnostic strategies have been

provided in hopes of validating the statistical figures available on children with ADHD.

Complicating our understanding, as well as treatment, of the disorder is that its

causes presently are unknown. Research investigations continue to explore several

possibilities, including

* Heredity or genetic causes

* Prenatal alcohol and drug exposure

* Lead poisoning

* Biological or physiological conditions

* Complications or trauma during birth (Montague & Warger, 1997).

Rosinsky (2001) reviewed new scientific imaging techniques that show the very

front of the brain-the area involved with controlling attention and inhibiting behavior-

may be smaller and less active in people with ADHD than in people without it. Magnetic

resonance imaging (MRI) has demonstrated that there is less blood flow in this area of

the brain. Positron emission tomography (PET) research measured less active nerve cells

in the frontal area of the brain of people with ADHD. Additionally, new research

addresses the hereditary nature of ADHD, focusing on specific genes that lessen the

availability of specific neurotransmitters (Rosinsky, 2001).

Ballard and colleagues (1997) explored the neurological basis of this disability.

The disorder is considered organic in pathology, particularly in regards to the central

10

nervous system functioning. The signs of neurological deficits were explored. A

person's ability to maintain attention, self-regulate impulsivity, and delay gratification are

all symptoms and, correspondingly, are prefrontal brain functions. This study also found

ADHD to be a biological disorder (with heredity playing a role) that can be exacerbated

by social factors. Segman, and associates (2002) continued to support exploring genetic

factors as important in locating the cause of ADHD. They found a variant gene sequence

in some children made them more susceptible to express symptoms of ADHD.

Behavioral Characteristics

ADHD is defined as a developmental disorder characterized by inappropriate

degrees of inattention, overactivity, and impulsivity (Barkley, 1990). These three key

domains are evident in all young children at times. The difficulty comes in ascertaining

when these behaviors are out of the ordinary and creating a handicapping condition

(Barkley, 1990). Excessive levels of ADHD-type behaviors impede developmentally

appropriate socialization, optimal learning, and positive parent-child interactions (Fewell

& Deutscher, 2002). ADHD has been reconceptualized as a disorder of executive control

and behavioral self-regulation rather than as an attention disorder (Fewell & Deutscher,

2002). ADHD results from deficits in rule-governed behavior that lead to problems

initiating, inhibiting, sustaining, or shifting responses to tasks or stimuli (Barkley, 1997).

ADHD has been broken into three subtypes. The classic ADHD-C category is

characterized by hyperactivity, impulsivity, and inattention. ADHD-HI is predominantly

hyperactive-impulsive behavioral disorder. ADHD-PI is the subtype that primary

symptoms are inattention (Chermak, Tucke, & Seikel, 2002). The three domains that

characterize this disorder are described as follows.

11

"Attention," the hypothetical, multidimensional construct used to describe,

organize, and even explain the collection of behaviors believed to reflect these essential

skills, is considered a critical precursor for optimum development and learning (Hagen &

Hale, 1973). Poor attentional skills are relatively common in childhood and are a

primary characteristic associated with ADHD. This classification results from behaviors

such as inattention to detail, careless mistakes in life activities, such as schoolwork, a

difficulty in sustaining attention and listening, incompletion of assigned tasks,

organizational skill deficits, losing and misplacing materials, being easily distracted,

avoiding tasks requiring sustained effort, and forgetfulness (D'Alonzo, 1996).

Attentional problems fluctuate and frequently depend on the situation. Children with

ADHD have been described as having an attentional bias towards novelty because they

seem to need more stimulation and variety than other children (Montague & Warger,

1997). Warner-Rogers, Taylor, Taylor and Sandberg (2000) examined inattentive

behavior in childhood. They indicate that inattentive behavior should be viewed as a

developmental problem rather than simple and normal variants of behavior. Inattentive

behavior was closely linked with adjustment problems in the classroom. Their study

functions to identify the implications of the presence of even a few inattentive behaviors.

Hyperactivity is another primary characteristic of ADHD (D'Alonzo, 1996).

This classification results from behaviors such as being fidgety, leaving assigned areas,

running about excessively, difficulty engaging or playing in activities quietly, appearing

to be in constant motion, and talking excessively (D'Alonzo, 1996). Students may make

noises at inappropriate time, leave their seats repeatedly without permission, and talk out

12

during quiet time. Research suggests that hyperactivity declines with age, however, the

early years of learning are interrupted by this extreme hyperactivity (D'Alonzo, 1996).

Impulsivity is the third predominant behavior of ADHD (D'Alonzo, 1996).

Students commonly blurt out answers before questions have been completed and have

difficulty taking turns, and interrupt when others are speaking and intrude on others. This

can get them into trouble or danger. Additionally, feelings of embarrassment arise when

they interrupt a class or conversations. Students with ADHD usually have difficulty

staying on task. They are distracted, appear not to listen, and seldom finish their work

without close supervision (D'Alonzo, 1996).

According to Brand, Dunn, and Greb (2002), common characteristics of their

learning style are found among children with ADHD. Significantly more than the general

population, these students with ADHD require soft lighting, intermittent relaxation

breaks, and either late morning, afternoon, or evening learning, dependent on the

individual. The diversity of behavior characteristics and the attributes generally ascribed

were not the cause of their inability to learn conventionally, but they simply evidenced

very different learning styles

Studies have reported that students with ADHD are more likely then others to

have a number of problems:

* Grade retention

* Delinquency

* Academic achievement

* Behavioral problems

* School Failure

13

* Drug abuse

* Social and emotional adjustment difficulties

* Dropping out of school (CHADD, 1995)

Interventions

Schachar and colleagues (2002) reviewed the variety of available treatments to

the heterogeneous population of children with ADHD. The need exists to acquire quality

information upon which to develop practice parameters for treating ADHD.

Interventions must be of sufficient intensity to have an immediate impact on the core

ADHD symptoms, and must be of adequate duration and intensity to alter adverse

outcomes (Schachar et al., 2002).

Pharmacological interventions

Pharmacological interventions are used to control and treat ADHD and continue

to escalate in popularity (Fewell & Deutscher, 2002). Medication therapy for children

with ADHD involves the intake of a substance that alters brain chemistry and thereby

changes the outward behavior of the affected child (Fewell & Deutscher, 2002). It is

estimated that between 70% and 90% of children will have a positive response to one of

the major stimulants when it is first prescribed (Goldman et al., 1998). Ritalin, Adderall,

Dexedrine and Cylert are all stimulants commonly used with these children. Research

indicates that on the days when psycho-stimulants are taken appropriately, these drugs

strengthen attention and weaken impulsivity and hyperactivity (Goldman et al., 1998). If

the medication is working, the child should be more able to concentrate, less distractible,

and more attentive. If aggressive and inappropriate behaviors exist, there should be a

decrease. Their impact on the nervous system is not completely understood, however

14

they can improve behavior with relatively few side effects. Because pharmacological

interventions help control, but not cure ADHD, concerned families may make different

decisions about their use.

Arnett and Fischer (1996) examined the effects of Ritalin on the response of

ADHD children to reward and punishment. Children with ADHD taking Ritalin showed

a significantly smaller response speed to reward cues. Additionally, the children

responded faster to punishment cues. This study suggests that Ritalin weakens the

behavioral responding of children with ADHD.

Research shows consequences for children subjected to the drug-therapy regiment

associated with ADHD (Barnett & Labellarte, 2002). . Side effects that concern parents

include weight loss, stomach pains, headaches and insomnia. The zombie effect of

stimulants is a distinct state of passivity that may be the result of dose-related

overstimulation formulated as "overfocus". The zombie effect is clinically distinct from

other activation symptoms and sedation (Barnett & Labellarte, 2002). Parents fear the

potential for future drug abuse. The risk of abuse increases when a child has a family

history of stimulant abuse. Meanwhile, studies need to continue to focus on the long-

term effects of stimulant medications. The adverse effects and repercussions associated

with drug therapy lead many researchers to endorse other alternatives to control attention

(Calhoun et al., 1997).

Approximately 30% of children do not respond positively to medication and

require other types of assistance in order to function successfully in the classroom. Even

among those who respond positively to medication, only a small number of children

demonstrate their behavior to fall within the normal range (Pelham, 1993). Additionally,

15

medication treats the symptoms of ADHD temporarily. Therefore, most children

receiving medication also require other types of interventions.

Behavioral Interventions

Behavioral interventions focus on changing observable and measurable behaviors

through the manipulation of the environment (Frazier & Merrell, 1997). The basic

behavioral treatment approaches used for students with ADHD include positive

reinforcement procedures (e.g. praise, attention, rewards), punishment procedures (e.g.

time-out), and combinations of both (e.g. token economies) (Frazier & Merrell, 1997).

Praise and approval can have an impact on the behavioral characteristics of children with

ADHD. Positive correlations between teacher approval and on-task behavior, and

concomitant negative correlations between teacher disapproval and on-task behavior,

suggest that teacher's use of approval and disapproval could be responsible for the

behavioral characteristics of children in classrooms (Beaman & Wheldall, 2000).

Students with ADHD need orderly organized classrooms where common routines and

rules are posted and reviewed as needed. One step in creating behavioral interventions is

to carefully plan reinforcement programs that include incentives and promote successful

performance rather than completion of a task. Students continue to show intrinsic interest

in their work even when the reinforcers are no longer present (Montague & Warger,

1997). Successful teachers of students who are distractible often suggest to reduce

unnecessary stimuli in the environment (e.g. preferential seating, reducing extraneous

objects). Additionally, developing cues or signals with the student that can be used to

redirect attention is beneficial. Behavioral interventions have many advantages including

no side effects, and both school and home setting utilization. Behavioral interventions,

16

however, are limited because there are many variables to influence the effect of the

treatment. Examples of the variables include settings, teacher training and utilization of

strategy, potency of reinforcers, and severity of the problem (Montague & Warger, 1997).

Research demonstrates that a strong classroom management system helps all

children develop positive and responsible behavior (Montague & Warger, 1997). Typical

management systems can be enhanced to address the unique characteristics of students

with ADHD. Clear and concrete rules, expectations, and consequences have to be

communicated, and sometimes explicitly taught to these students. Also, carefully

planned reinforcement programs including incentives to promote student successful

performance are an essential component of the management system. Student

performance should be monitored daily to sustain motivation and active involvement.

Verbal praise and positive feedback enhance students' intrinsic interest in tasks

(Montague & Warger, 1997).

Reis (2001) supported the use of positive reinforcement after conducting field

observations. This study calls the teacher's attention to the frequency of negative

comments the students with ADHD receive. Once the teacher is aware of the overuse of

negative comments, he/she can replace these comments with positive verbal praise. The

use of positive verbal praise goes a long way toward fostering better self-esteem for

learners with ADHD (McCluskey & McCluskey, 1999). A student's self-esteem or self-

worth is fostered when the teacher creates a classroom environment in which the student

with ADHD feels his or her efforts will be recognized. Through such recognition, the

student with ADHD can perceive that they have competencies and that they will succeed

17

at school-related tasks. Student efforts increased in response to the positive comments as

well as a decrease in the frequency of negative behaviors.

Techniques, which prevent misbehavior from occurring, are important for

teachers to use to manage their classroom. Reif(1993) found crucial factors including

clarifying expectations such as teaching what is acceptable/unacceptable; providing

structure, routine and consistency; practicing, modeling and reviewing behavioral

expectations and rules; delineating clear and fair consequences; and showing

understanding, flexibility, and patience. The classroom is one arena to reinforce, model,

and practice positive character traits on a daily basis. These character traits must be

taught and modeled throughout the curriculum.

Behavioral interventions also have limitations. They are not effective for all

children (Pelham, 1991). For example, it can be quite difficult to get consistent

implementation over an extended period of time. Also, there is lack of evidence

supporting the long-term effects and generalizability of behavioral interventions (Pelham,

1991). Thus, a variety of factors must be considered and directly utilized for behavioral

treatments to be optimally effective.

Cognitive Interventions

The importance of cognitive control in human behavior was addressed in

1970s. Cognitive factors partly determine which external events will be observed, how

they will be perceived, whether they will leave any lasting effects, what valence and

efficacy they have and how the information they convey will be used for future use

(Bandura, 1977). Most external influences affect behavior through intermediary

cognitive processes. Cognitive representations of future outcomes function as current

18

motivators of behavior (Bandura, 1977). Self-motivation requires standards against

which performance is evaluated. When individuals commit themselves to explicit goals,

perceived negative discrepancies between what they do and what they seek to achieve

create dissatisfaction that serve as motivational inducements for change (Bandura, 1977).

Self-motivation through self-reactive influences, wherein individuals observe their own

behavior, set goals, and reinforce their performances, is a major factor in a variety of

motivational phenomena (Bandura, 1977). Self-motivation is best maintained by explicit

proximate subgoals that are instrumental in achieving larger ones (Bandura, 1977).

Cognitive intervention strategies are implemented on the premise that changes in

thinking will result in changes in behavior (Cipani, 1991). Implementing observational

learning, self-instruction, and self-motivation strategies are ways to cognitively intervene.

According to Cipani (1991), observational learning is a cognitive approach that results in

students acquiring information about how to behave in a particular environment by

observing others. Through modeling, students attend to the behavior exhibited by others

and begin to approximate their actions. This observational learning is modeled and role-

played during planned activity time. Self-instruction involves the use of self-statements

to assist in regulating behaviors that often interfere with effective learning and

performance. Initially, students are taught to verbalize to themselves, a teacher or

classmate, ways to solve the problem. Over time, the statements become more covert

(Cipani, 1991). These interventions have experienced limited independent use with

children with ADHD, and cognitive-behavioral interventions have been suggested.

19

Comnitive-behavioral Interventions

These interventions derive from traditional cognitive interventions in conjunction

with basic behavioral techniques. Cognitive-behavioral interventions emphasize the

influence of internal cognitions on self-control (Cipani, 1991). Specific techniques teach

self-control through increased awareness of cognitive processes and knowledge of how

behavior affects academic and behavioral outcomes (Swaggert, 1998). Cognitive-

behavioral interventions encompass a number of strategies with self-management being

the most important factor. The student continuously evaluates his own progress, unlike

behavioral interventions that are evaluated by the teacher. Additionally, these

interventions are advantageous because students can generalize to multiple environments.

This type of intervention is not just managing the symptoms of ADHD, rather providing

for continued growth and rehabilitation of ADHD symptoms. Reinforced self-evaluation

has been used to improve the behavior of ADHD children. As a result, greater amounts

of appropriate social behavior and decreased amounts of negative social behavior were

found among boys with ADHD compared with boys using pharmacological and

behavioral interventions (Hinshaw, Henker, and Whalen, 1984). Reviewing research

cases of students with ADHD, Hinshaw and Melnick (1992) concluded that cognitive-

behavioral strategies aid in generalization and maintenance by extending the salience of

contingencies in the child's mind, promoting self-monitoring and self-evaluation, and

enhancing both self-reward and problem solving.

Self-monitoring or self-recording is a particular set of strategies whereby the

student is taught to discriminate targeted behaviors and to record the occurrence and/or

nonoccurrence of these behaviors during predetermined time intervals within a given

20

session or activity. Self-monitoring interventions have proven to be dramatically

effective in reducing challenging behaviors with individuals with severe disabilities

(Koegel & Koegel, 1990). These techniques may potentially enhance independent

activity while decreasing challenging activities in the classroom (Koegel & Koegel,

1990).

Swaggert (1998) discussed the procedures necessary to successfully implement

this technique. Implementing self-monitoring procedures requires the teacher to engage

in pretraining activities. The teacher selects one observable target behavior that the

student demonstrates to monitor. Then the teacher gathers the necessary materials to

implement the strategy. Initially, the intervals that the student monitors should be brief.

Subsequently, the initial periods should include reminders of the desired behavior as well

as praise. Students will require prompts and feedback to ensure accurate recording and

the teacher should keep records in order to compare the accuracy.

Mathes and Bender (1997) investigated the combined treatment approach of an

intensive cognitive-behavioral intervention coupled with a pharmacological treatment

plan in a classroom setting. The participants were elementary school boys who were

experiencing mild to severe problems in their general and special education classrooms.

The goal was to increase on-task behavior of the students with ADHD who had been

receiving medication. The students were trained to self-monitor on-task and off-task

behavior after these behaviors were clearly defined. They were actively involved in

monitoring their on-task behavior and recording it each day. After ten days of the

intervention, the fading phase took place. During this phase, the self-monitoring sheet

and cuing tape were removed. This study produced many positive outcomes. During all

21

phases, percentages of on-task behavior remained much higher then those in the baseline.

Finally, teachers supported the intervention and noted increased percentages of accuracy

on the students' work. The data demonstrated that self-monitoring is a very effective

procedure to increase attentional behavior among elementary students.

Peterson and Young (1999) reported the effects of a student self-management

procedure, involving self-monitoring and teacher matching. A teacher and classroom

aide were trained in the implementation of self-management in the classroom. The

program emphasized, direct teaching, instructional praise, corrective teaching, and

behavioral directives, with the use of modeling, role-playing and performance feedback.

A rating scale was selected and completed on a self-management form. Points were

awarded for scores on their self-management form matching that of the teacher's

recording. Students participated in a reinforcement time where they were able to earn

pens, pencils, additional game and computer activities. Eventually the program was

generalized to other classes in the school. This self-management procedure was effective

in generalizing appropriate behaviors across multiple settings. The implications of this

study are that a practical, feasible process involving minimal teacher time and effort can

support a significant change of behavior (Peterson & Young, 1999).

Hutchinson, Murdock, Williamson, and Cronin (2000) implemented a

combination of self-monitoring strategy with point awards, teacher praise, and

encouragement to decrease the time it took a child with ADHD to begin an assignment

and to increase his on-task and nondisruptive behaviors. The first grade student received

training on how to complete a self-recording form including ten items. The student

recorded his own behaviors and earned rewards at home based on the points on the

22

record. The results showed that the student's time to begin working decreased and his

on-task behaviors increased. Meanwhile, the student, teacher and guardian were all less

frustrated with working on decreasing the behaviors associated with ADHD. It is also

found that these methods are an effective, inexpensive way to modify the inappropriate

behavior (Hutchinson, Murdock, Williamson, & Cronin, 2000).

O'Reilly, Tiernan, Lancioni, Lacey, Hillery and Gardiner (2002) studied the use

of self-monitoring to increase the on-task behavior of a child who frequently moved,

rocked in her seat, and gazed. A functional assessment was conducted to determine when

these off-task behaviors most frequently occurred. The student was initially trained using

modeling of on-task and off-task behavior. Then the student was instructed on how to

use the wristwatch and self-recording sheet to monitor the behavior, and to demonstrate

accuracy in recording the target behavior in the training sessions. Once the student

mastered the recording skills, this strategy was implemented in one classroom. The

results in that class were immediately positive and the student was able to successfully

generalize into other classes. The feedback was provided at the end of each class to

increase the on-task behavior. The teachers noted dramatic positive changes in the

student's behavior at the end of the program and found, the intervention was not intrusive

to her classroom.

Self-monitoring strategies have yielded positive results in the majority of research

for various ages, genders, and disabilities of students, including ADHD, autism, and

mental retardation (e.g. generalization to additional settings, increased on-task behavior,

improved learning) (Frazier & Merrell, 1997). However, some researchers have reported

limited gains (e.g. little empirical support) (Abikoff, 1991). Success with this type of

23

intervention is dependent on the individuals involved, such as, teacher and children's

willingness and active participation. This type of intervention may not be practical and

useful to promote sustained behavior change for all children, however, it should be

considered a valuable tool in managing behaviors associated with ADHD (Frazier &

Merrell, 1997).

Summary

An intense review of literature summarized the approaches to intervene with

inappropriate behaviors of children with ADHD. Various intervention strategies have

been practiced as a means to control the behaviors including pharmacological,

behavioral, cognitive, and combined cognitive-behavioral models. However, the need

exists to continuously explore new perspectives to meet the growing need of children

with ADHD.

The cognitive-behavioral approaches are an effective procedure as part of a

comprehensive program to meet the full array of needs of this population. This present

study will address the utilization of this approach with young students with ADHD

together with other disabilities. By replicating the study by Hutchinson and colleagues

(2000), more information will be added on the effect of the cognitive-behavioral

approach in elementary classroom practice for managing behaviors of students with

ADHD.

24

CHAPTER 3

METHOD

Subjects

Three first and second grade boys attending an elementary school in Southern

New Jersey participated in the study. These students were diagnosed with ADHD by

their physician and classified to be eligible for special education services through their

Individualized Education Plan (IEP) according to the state code (2001). They were

placed in a self-contained special education classroom for students with disabilities.

The students had experienced significant behavioral difficulties in school and

displayed behavior problems that interfere with class activities. The most prevalent

inappropriate behavior was off-task behavior. This target behavior was defined as

leaving seat, calling out answers, and interrupting instruction.

STUDENT 1-Student 1 is a 7-year old male who has been eligible for special educationfor 3 years as a result of his diagnosis of ADHD and PDD/Autism.

STUDENT 2- Student 2 is a 6-year old male who has been eligible for special educationfor 2 years as a result of his diagnosis of ADHD and EmotionalDisturbance.

STUDENT 3- Student 3 is a 7-year old male who has been eligible for special educationfor 2 years as a result of his diagnosis of ADHD and Mild CognitiveImpairment.

Setting

Students' behavior was observed in Reading and Math in a special education

classroom located in a community with low socio-economic status in Southern New

Jersey. There are eight-second graders and three first graders in the classroom. These

students have various special education classifications, ranging from emotionally

disturbed to cognitively impaired. One dually certified regular and special education

25

teacher instructs the class together with three teacher assistants to support the

students in the classroom.

Research Design

An A-B-A-B withdrawal design was used to determine whether self-monitoring

strategy combining with positive reinforcement would decrease the off-task behavior.

Initially, baseline data was collected for one week, then the intervention strategy was

introduced for two weeks, then the intervention strategy will be withdrawn for two weeks

and finally the intervention strategy for three weeks will be repeated and reinforced. The

repeated application and withdrawal of the intervention condition will make it possible to

determine the change of the behaviors being measured.

Training Materials

Students were taught to self-monitor their behaviors. They received a self-

recording checklist form that consists of 7 items. Items 1,2,6 and 7 are on-task behaviors

and items 3-5 are nondisruptive behaviors. The students were instructed to complete the

form by marking an "X" on the items, when they demonstrated the target behavior

successfully (See Figure 1). A decrease in target behavior was positively reinforced.

Training Procedures

Students participated in three training sessions on how to complete the self-

recording checklist called "GREAT DAY!". At the first session the target behavior of

off-task will be defined, and on-task will be explained. On-task means answering

questions, working independently, and staying in the seat. Examples will be given and

modeled. The final two training sessions will emphasize accurate completion of the form

(See Figure 2 for procedures).

26

Observation Procedures

Two teacher assistants will record the frequency of the off-task target behaviors

including leaving seat, calling out answers, and interrupting instruction during ten-minute

intervals in Reading and Math throughout the day, when the target behavior is observed,

an "X" needs to be marked as occurrence and, "-" for non-occurrence (See Figure 3).

The observers will calculate the percentage of time the students' were on-task by dividing

the number of times the student was off-task by the number of intervals. The percentages

would be used to match the student's record of their own behavior presented on the self-

recording form.

Interobserver Reliability

Two independent observers will complete the frequency observation form to

record the student' off-task behaviors. At the end of observation, both observers will

meet to check their observation data. The interobserver reliability will be calculated by

agreement/ total intervals, and 60% of agreement and above should be reached.

27

Figure 1: Self-Recording Form

GREAT DAY

28

Date

1. I did my work by myself.

2. I answered questions.

3. I did not laugh at others. m

4. I did not talk out loud.

5. I did not hit anyone

6. I started my work when asked.

7. I stayed in my seat. I

Figure 2: Training Procedures

29

Session 1: Defining Session 2: Self- Session 3: PracticeRecording Checklist Completing Form

Target Behaviors

* Identify 3 behaviors * Review behaviors * Review behaviors

* Model behaviors * Discuss form * Review form

* Introduce form * Provide examples * Practice completingform in various lessons

* Ask questions

CHAPTER 4

RESULTS

An A-B-A-B withdrawal design was used in this study. Observations were

conducted during the baseline for five days prior to the self-management training, then

continued during the intervention phase for ten days using the self-management strategy.

Observations continued for baseline data by withdrawing the intervention for 5 days, then

completed with 10 days of intervention using self-management. Figures 4.1, 4.2, and 4.3

present the results.

Figure 4.1

Out of Seat

'7 no

---- Student 1

-- Student 2

^ Student 3

30

I U A)

60%

50%

C 40%a)

v 30%LL

20%

10%

0%I0C) 1i) I,- 03) C) U,) - 0) T- C U) P- 0) .T)- 0 I U) '- 0)

fats e n n- T-eCrio C C c CB n C') I Co C) XC

Baseline 1 Intervention 1 Baseline 2 Intervention 2

Figure 4.2

Calling Out

,~3 Al.

-- -Student 1

--- Student 2T- CY) LC) N- 0) T- C-r) LO rN- 0C) - Cr) O (c) N c r) O IC - O)

- V i- I- - ^- CN ( (N CN C O) n C C)

Baseline 1 Intervention 1 Baseline 2 Intervention 2

Figure 4.3

^ ' Student 3

A. - -Student1r- Ji m Student 2

l ... -- .Student 3.,~ i ...........

CY) L) N,-- ) 1-- Cr) t) i- (30) - CY) UC) N- 0) T- Cr)3 1' N- 0)Baseline I InterventioN N N 2 Interventio n 2

Baseline 1 Intervention 1 Baseline 2 Intervention 2

31

30%

25%

I 20%

e 15%LL

10%

5%

0%

0%

Figure 1 shows the percentage of each student's out-of-seat behavior during the baseline

and intervention phases. During the baseline, of the total of 5 days in 5-minute intervals

during various lessons throughout the day, students presented a high level of out- of-seat

behavior. When the self-management strategy was taught to students and implemented in

class during the intervention phase, out-of-seat behavior was reduced, and the

decelerating trend was consistent in both intervention and follow-up phases. However,

the data was variable from one student to another during the short time period.

Figure 2 shows the percentage of each student's calling out behavior during the

baseline and intervention phases. During the baseline, of the total of 5 days in 5-minute

intervals during various lessons throughout the day, students presented a high level of

calling out behavior. When the self-management strategy was taught to students and

implemented in class during the intervention phase, calling out behavior remained at a

high level. However, the data was variable from one student to another during the short

time period.

Figure 3 shows the percentage of each student's interrupting instruction during

the baseline and intervention phases. During the baseline, of the total of 5 days in 5-

minute intervals during various lessons throughout the day, students presented a high

level of interrupting instruction. When the self-management strategy was taught to

students and implemented in class during the intervention phase, interrupting instruction

was reduced. However, the data was variable from one student to another during the

short time period.

32

Chapter 5

DISCUSSIONS

The purpose of this study was to examine the effect of the self-management

strategy together with positive reinforcement to reduce inappropriate behaviors of

students with ADHD. The target behaviors were: out-of-seat, calling out, and

interrupting instruction. These students were trained to use the self-management strategy

in their special education classroom over a thirty-day period in school.

The first research question was to examine the effectiveness of this intervention to

reduce the out-of-seat behavior of the students. The results indicated when self-

management was implemented for ten days in Intervention, phase B student's out-of-seat

behavior was reduced. While the intervention was withdrawn for five days during the

Baseline, phase A, student's out-of-seat behavior resumed. During the Intervention II,

when the self-management strategy was applied again for ten days the student's out-of-

seat behavior was reduced. A decelerating trend was shown in both intervention phases

of 3 students. The results indicated a decrease of out-of-seat behavior, however an

extended period of time would have strengthened the results of the study if the study

were continued.

The second research question was to examine the effectiveness of this

intervention to reduce the calling out behavior of the students. The results indicated

when self-management was implemented for ten days in Intervention, phase B, students'

calling out behavior remained at a high level. Students' calling out behavior

33

continued at elevated levels when the intervention was withdrawn for five days of

Baseline IL During the final ten days of resumed Intervention, phase B, the student's

calling out remained at a high level. It appears that calling out behavior is difficult to

reduce because of different rules in different classes. The behavior was observed in

different classes, reading, math and writing. Calling out might be allowed for some

classes because of the type of instruction and classroom environment.

The third research question was to examine the effectiveness of this intervention

to reduce the student's behavior of interrupting instruction. The results indicated when

self-management was implemented for ten days in Intervention, phase B, students'

behavior of interrupting instruction was reduced, however, the data were variable. When

the intervention was withdrawn for five days this behavior was resumed. It became

consistently reduced for the final ten days of Intervention II. Even though the behavior

of interrupting instruction was reduced, data were variable from student to student.

When comparing these results with Hutchinson et al. (2000)'s study, some

similarities and differences can be found. In both studies, positive results were indicated

using self-management strategy together with behavior modifications, however, neither

study indicated whether self-management alone would have been effective. In addition,

the participants in both studies were satisfied with the improved behavior. However, a

major difference between the studies concerned the reduction of disruptive behaviors,

including calling out. In Hutchinson's study it was found that using self-management

strategy could reduce the occurrence of calling out behavior. It may be that classroom

and instructional conditions in the advanced reading group in her study restricted the

34

occurrence of this behavior. In the present study, the students in the special education

classroom had limited success in decreasing calling out behavior, because the rules in

instruction and environment may have fewer constraints.

There are some limitations in the study. First, the findings are limited by the short

time period to collect all the data. The students were provided with limited training in

using the self-management strategy. If time permitted, students may have benefited

from gradually using the strategy in one subject and slowly moving to a whole day of

self-management. Additionally, absences and other school related services interrupted

and limited the amount of time the students were involved in the classroom. In addition,

the sample size was limited to three primary elementary students in special education.

Their disabilities may have impacted their ability to effectively utilize the strategy. It

seems that older students may benefit from using this strategy. Further, these students

were only observed in one classroom setting and possible differences in other classrooms

were not examined. Given these limitations, the results indicate the decrease of student

inappropriate behaviors, however; more consistency would have strengthened the results

of the study. When selecting participants, a group of homogenous students with similar

classifications and cognitive levels may show more stable data to strengthen the

consistency of behavior occurrences.

Overall, the findings of the present study provide support to the previous study to

suggest a cognitive-behavioral approach to students with ADHD. Given the limitations

of the present study future studies may need a longer time period for students using self-

management strategies. In addition, a comparison of how students with higher and lower

35

cognitive abilities using self-management may be needed to examine if any differences

may exist. Various strategies from medical, behavioral and cognitive perspectives have

been tried to change inappropriate behaviors of students with ADHD. Self-management

has been proven to be effective for this group of students. The present study has

provided data to support the finding in the previous research and added data to the

effectiveness of self-management for children with ADHD at the primary elementary

school level.

36

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40

APPENDICES

41

Lesson Plan: Day 1

Objective: To introduce and define three target behaviors, to introduce students to theself-recording form

Procedure: 1. Take the three students to an unoccupied classroom and explain theirspecial project 2. Use the chalkboard to list the three-targeted behaviors

3. Use examples to define the behaviors in words. 4. Model appropriateon-task and inappropriate off-task behaviors. 5. Ask students to modelinappropriate off-task behaviors and appropriate on-task behaviors.

6. Provide praise and feedback 7. Introduce the self-recording formusing the overhead

Evaluation: Participation

Lesson Plan: Day 2

Objective: To review the target behaviors, to introduce how to complete theself-recording checklist

Procedure: 1. Use modeling to review the three target behaviors 2. Pass out checklistand go over each item 3. Model how to complete the checklist4. Provide oral examples and students decide if that affects the checklist5. Ask questions to ensure student understanding

Evaluation: Participation, completion of form

Lesson Plan: Day 3

Objective: To review the target behaviors, to review the self-recording checklist, topractice using the self-recording checklist in class

Procedure: 1. Match the target behaviors to the appropriate definition on thechalkboard 2. Pass out form and review each item 3. Return tothe classroom and participate in reading class 4. Return tothe unoccupied classroom and have students complete form withteacher reading each item 5. Discuss any concerns 6. Repeat withvarious lessons, praising appropriate completion

Evaluation: Participation, completion of form

Dear Parent/Guardian:

I am a graduate student in the Special Education Department at Rowan University. I willbe conducting a research project under the supervision of Dr. Joy Xin as part of mymaster's thesis concerning the effects of specific strategies when working to increase theon-task behavior of students. The goal of the study is to determine if these specificstrategies will improve student's behavior.

The goal of the study is to decrease the number of off-task behavior occurrences in theclassroom. Classroom instruction will remain the same. Names will be withheld in theproject and results will be strictly confidential.

Your decision whether or not to allow your child to participate in this study will haveabsolutely no effect on your child's standing in his/her class. At the conclusion of thestudy a summary of the group results will be made available to all interested parents. Ifyou have any questions or concerns please contact me at 884-9470 or you may contactDr. Joy Xin at (856) 256-4747. Thank you.

Sincerely,

Cari McGaffney Bonner

Please indicate whether or not you wish to have your child participate in this study bychecking the appropriate statement below and returning this letter to your child's teacherby

_ I grant permission for my child to participate in this study.

_ I do not grant permission for my child to participate in this study.

(Parent/Guardian Signature) (Date)